Holgate House

On this page

• Overview
• Learning culture
• Safe systems, pathways and transitions
• Safeguarding
• Involving people to manage risks
• Safe environments
• Safe and effective staffing
• Infection prevention and control
• Medicines optimisation

Safe – this means we looked for evidence that people were protected from abuse and avoidable harm. At our last assessment we rated this key question requires improvement. At this assessment the rating has changed to good. This meant people were safe and protected from avoidable harm.

This service scored 66 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The provider had a developing culture of safety, based on openness and honesty. Staff were being upskilled to recognise concerns about safety and escalate these to be investigated. There was a growing culture of lessons being learnt to continually identify and embed good practice.There had been challenges within the service recognising and responding to concerns and incidents but improvements were being made under new leadership. The new manager was working with the provider and staff team to develop improvements and embed a culture of learning.

The provider worked with people and healthcare partners to establish and maintain safe systems of care, in which safety was managed or monitored. They made sure there was continuity of care, including when people moved between different services.The staff team had a good working relationship with partners such as GP, social workers and mental health staff. Staff knew people well and were able to effectively communicate people’s situation and care needs.

The provider worked with people and healthcare partners to understand what being safe meant to them and the best way to achieve that. Staff concentrated on improving people’s lives while protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. The provider shared concerns quickly and appropriately.Staff had a good understanding of what safeguarding was and all staff had been trained on safeguarding. People felt safe living at the service and told us they did not have any concerns about their safety.

The provider did not always work with people to understand and manage risks. Staff were always provided with written guidance on how to meet people’s needs that was consistent and enabled people to do the things that mattered to them.Care plans had basic information within them and in all cases did not explore how to involve people in managing risks and focusing on what mattered to them. While people were largely kept safe, there was little exploration of how people made unwise decisions which could impact their safety and how this could be monitored and people guided to make alternate choices.

The environment needed renovation, refurbishment and improvement to ensure it was maintained to a good standard. While the premises were safe, it was worn. The provider was aware of this and had already made a commitment to renovate the property with improvement works due to start shortly after the inspection.

The provider made sure there were enough qualified, skilled and experienced staff, who received effective support, supervision and development. They worked together well to provide safe care that met people’s individual needs.There was a stable staff team who knew people well and staff cover was maintained so people always had access to the support they needed. People told us they did not need to wait a long time if they needed support. Staff were recruited safely and they had regular support from leaders.

The provider assessed and managed the risk of infection. They detected and controlled the risk of it spreading and shared concerns with appropriate agencies promptly.Staff were observed following correct infection control processes. Staff were trained in how to use personal protective equipment (PPE) and how to manage infection transmission. The manager was reinforcing the importance of effective infection management within the staff to build confidence within the staff team.

The provider made sure that medicines and treatments were safe and met people’s needs, capacities and preferences. Staff involved people in planning, including when changes happened.The medication risk assessments did not always identify the risks associated with the administration of some medicines. The provider was aware of this, and the improvements needed had been identified on their action plan. Additional information about the administration of medicines prescribed on a when required basis were present in the form of when required protocols. However, the information included in some of these plans was not sufficient to inform the staff of how and when it was appropriate to administer these medicines. The provider was aware of this, and the improvements needed had been identified on their action plan.